Pediatric emergency medicine trisk 1114
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FIGURE 130.48 Peripheral nerve block for regional anesthesia. A. Digital and metacarpal.
B. Supraorbital nerve. C. Infraorbital nerve. D. Mental nerve.
Procedure
The supraorbital nerve exits the skull at the foramen just above the supraorbital
ridge. The supratrochlear nerve exits just medial to the supraorbital nerve. Locate
the foramen by palpating over the medial aspect of the supraorbital ridge ( Fig.
130.48B , top).
Cleanse the area with antiseptic solution. Insert a 27- or 30-gauge, 1- to 1.5-in
needle just medial to the foramen, directed toward the foramen ( Fig. 130.48B ,
bottom). After inserting the needle and advancing the tip, inject 1% lidocaine
with epinephrine in a fan-like distribution along the superior orbital rim. If
paresthesia of the forehead is noted in the verbal patient during advancement of
the needle, redirect the needle to avoid injecting directly into the nerve.
Infraorbital Nerve Block (Intraoral Approach)
Indications
1. Lacerations within sensory distribution of the nerve ( Fig. 130.48C , part A)—
midface (skin of the upper lip, nose, and lower eyelid)
2. Removal of a foreign body
Procedure
The infraorbital nerve exits its foramen just below the infraorbital ridge. Locate
the foramen by palpating for the notch along the inferior orbital rim.
Don gloves and place a finger over the infraorbital ridge while using the index
finger to hold up the upper lip. Numb the upper gum near the canine with a
topical anesthetic such as viscous lidocaine. Insert a 27-gauge, 1.5-in needle on a
syringe with 1% lidocaine. Puncture the gum line along the long axis of the
canine and advance until the needle tip is located just inferior to the foramen
where the infraorbital nerve exits ( Fig. 130.48C , part B). The needle is inserted
to about a depth of 2 cm in a full-grown teenager. Inject 1% lidocaine in a fanlike distribution inferior to the foramen. Wait 5 minutes for anesthesia to occur.
Mental (Infraoral) Nerve Block
Indications
1. Lacerations of the lower lip and chin
2. Removal of a foreign body
Procedure
The mental nerve is a branch of the alveolar nerve with sensory distribution of the
lower lip and chin ( Fig. 130.48D , top). It exits its foramen in the mandible at the
level of the premolar. Locate the foramen by palpating over the mandible in line
with the supraorbital and infraorbital foramen ( Fig. 130.48D , bottom).
Cleanse the area with antiseptic solution. Insert a 27- or 30-gauge, 1- to 1.5-in
needle just medial to the foramen directed toward the foramen. Depending on the
size of the child, insert the needle approximately 0.5 cm and inject 1 to 2 mL of
1% lidocaine with epinephrine in a fan-like distribution around the foramen. If
paresthesia of the lower lip is noted in the verbal patient during advancement of
the needle, redirect the needle to avoid injecting directly into the nerve.
SPLINTING OF MUSCULOSKELETAL INJURIES
General Splinting
Indications
To provide short-term stabilization and/or protection of musculoskeletal injuries
(fractures, tendon injuries, lacerations, or tenosynovitis)
Complications
1. Neurovascular compromise
2. Pressure ulcers
3. Contact dermatitis
4. Contracture if prolonged splint or not in position of function
Equipment
1. Cotton undercast padding (e.g., Webril)
2. Plaster slabs or rolls (2-, 3-, 4-, and 6-in widths) or prepadded material (e.g.,
Orthoglass) of same widths
3. Room temperature tap water
4. Elastic bandage
5. Adhesive tape or bandage clip
Procedure
Determine the style of splint needed based on anatomic considerations of the
injury. The injured extremity should be splinted in a position of function to
minimize the risk of contractures. Skin lesions and wounds should be cleansed,
repaired, and dressed in the usual manner before the application of a splint. Open
fractures should be evaluated emergently by an orthopedic surgeon.
Neurovascular status should be documented before and after the splint is applied.
Before applying the splint, it is important to completely expose the extremity to
be splinted and anticipate the child’s ability to remove his/her clothing once the
splint is applied.
Plaster Splint
Measure and cut the appropriate length of plaster. It is better to cut the length
slightly longer than necessary to account for any shrinkage. If the cut length is too
long, the end can be folded on itself. The upper extremity requires 8 to 10 layers;
the lower, 12 to 14 layers to withstand some weight bearing. In general, the width
of the material should cover approximately one-half of the circumference of the
extremity but should not be so wide that it completely encircles the extremity or
overlaps itself.
Next, prepare the padding. If toes or fingers are to be incorporated within the
splint, place padding between the digits to prevent maceration. Roll the cotton
undercast padding (e.g., Webril) around the injured extremity in a distal to
proximal manner, making sure to overlap each turn by 50%. Extend the padding 2
to 3 cm distally and proximally beyond the area to be splinted. Wrinkles in the
padding can create pressure points and are best avoided by stretching and/or
partially tearing the padding during application. Bony prominences require
additional padding to minimize pressure injury. Stockinette may be used under
the padding if desired.
An alternative method is to pad the splint material itself prior to applying to the
patient. This is achieved by layering the cotton undercast padding along the
aspect of the splint that will come into contact with the patient’s extremity. The
padding is unrolled back and forth along the length of the splint to achieve
enough cushion to prevent pressure injury.
Immerse the plaster slab in room-temperature water until bubbling stops.
Because setting plaster elaborates heat, room temperature water is recommended
to minimize risk of heat injury to the patient’s skin. Remove the slab from the
water and on an absorbent surface such as a towel; smooth the plaster to remove
excess moisture and wrinkles and to laminate the layers. The setting time of the
plaster is determined by the temperature of the water and the overall moisture
content of the plaster, with warmer water and drier plaster shortening the set time.
Properly position the splint onto the extremity. Using your palms, smooth and
contour the splint to the extremity, taking care not to leave indentations.
Indentations create pressure points that will be uncomfortable and cause skin
breakdown. Fold the exposed cotton padding back over the ends of the splint.
Next, an optional layer of gauze or a single layer of cotton padding may be
placed over the splint to prevent the elastic bandage from adhering to the plaster
as it sets. Roll the elastic bandage over the splint in a distal to proximal manner
and secure with tape or clips. The extremity should be maintained in the desired
position until the splint is sufficiently hard.
Fiberglass Splint
